Michael Hillitt

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Michael Hillitt,
a prisoner at HMP Parc,
on 18 May 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. Mr Michael Hillitt died from breathing difficulties in hospital on 18 May 2023, while a
prisoner at HMP Parc. He was 72 years old. We offer our condolences to Mr Hillitt’s
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Hillitt received at Parc was
of a very high standard and at least equivalent to that which he could have
expected to receive in the community. He asked that his recognition of the efforts of
the staff involved in Mr Hillitt’s care to be passed on to them.
5. We found no non-clinical issues of concern. We make no recommendations.
6. This version of my report, published on my website, has been amended to remove
the names of staff and prisoners involved in my investigation.
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The Investigation Process
7. HMPPS notified us of Mr Hillitt’s death on 18 May 2023.
8. Healthcare Inspectorate Wales (HIW) commissioned an independent clinical
reviewer, to review Mr Hillitt’s clinical care at Parc. The clinical reviewer’s report is
attached as Annex 1.
9. The PPO investigator investigated the non-clinical issues relating to Mr Hillitt’s care.
10. The PPO family liaison officer wrote to Mr Hillitt’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies.
Previous deaths at HMP Parc
12. Mr Hillitt was the 20th prisoner to die at Parc since May 2020. Fifteen of the previous
deaths were from natural causes, three were from drugs and one was self-inflicted.
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Key Events
13. On 13 January 2020, Mr Michael Hillitt was convicted of sexual offences and was
sent to HMP Parc. On 3 March, he was sentenced to 20 years imprisonment.
14. When Mr Hillitt arrived at Parc, he was morbidly obese. He weighed 198kg and had
a body mass index (BMI, a scale for assessing healthy weight) over 56 (the healthy
range is 18.5 to 24.9). He had health issues related to this including very restricted
mobility (he was a wheelchair user), and severely oedematous legs (a build-up of
fluid in the legs causing swelling and often skin problems). He also had chronic
obstructive pulmonary disease (COPD - the term for a group of serious lung
diseases), heart disease, and hypertension (high blood pressure). Mr Hillitt required
help with applying lotion and dressings to his legs on a regular basis while he was
at Parc.
15. Soon after his arrival at Parc, Mr Hillitt’s blood test showed abnormal results and a
GP at the prison suggested that he should be tested at hospital for possible
prostate cancer. Mr Hillitt refused at the time and only finally agreed a year later.
The hospital confirmed that Mr Hillitt had prostate cancer in September 2021. Mr
Hillitt refused any treatment.
16. Initially, Mr Hillitt successfully lost weight and by July 2021, he was down to 150kg.
In 2022, he started putting weight back on and by May, he was up to 180kg.
Healthcare staff told him that this would impact his health. Mr Hillitt said that he
managed his mental health problems by comfort eating.
17. On 2 February 2023, Mr Hillitt’s blood test once again showed abnormalities. A GP
suspected possible bowel cancer and to rule it out referred Mr Hillitt for an urgent
hospital appointment. However, Mr Hillitt refused to go and continued to do so even
though staff clearly explained to him the implications of not going for tests. He also
said that he would not go for any further follow up appointments for his existing
prostate cancer. There was no issue with Mr Hillitt’s mental capacity to make these
decisions. He said that the quality of his life in prison serving a long sentence was a
factor in his decision making.
18. During 2023, Mr Hillitt complained of increasing breathlessness, and although he
was seen by healthcare staff for this, there were no concerns inconsistent with his
existing health conditions. On 11 May, Mr Hillitt was once again breathless, and his
blood oxygen levels dropped. The out of hours GP advised that Mr Hillitt should go
to A&E. However, when paramedics attended in the evening, they said that his
observations were consistent with someone with his level of COPD and that he
should be seen by a GP in the prison the next day, rather than be taken by them to
hospital.
19. In the early hours of the next morning, Mr Hillitt fell out of his wheelchair. Because
of his weight, healthcare staff at Parc could not get Mr Hillitt back up. Staff
requested paramedics who arrived about four hours later and assisted Mr Hillitt off
the floor. He did not appear to be injured and the paramedics said that he did not
need to go to A&E.
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20. Later that day, Mr Hillitt’s condition slowly deteriorated. His breathlessness and low
blood oxygen levels concerned healthcare staff, and as he previously had abnormal
blood test results, healthcare staff decided that Mr Hillitt should go to hospital.
Because of his size, the only transport capable of taking him there that evening was
an ambulance. Staff requested one at around 10.30pm and it arrived around
3.30am on 13 May. Paramedics took Mr Hillitt to hospital about an hour later.
21. Mr Hillitt remained unwell in hospital and continued to deteriorate. He was given
supplemental oxygen to assist with his breathing but doctors said that there was no
treatment that was available to enable Mr Hillitt to recover. By 18 May, he was
being given palliative care (care with the focus on optimising the quality of life and
reducing suffering) by hospital staff. Mr Hillitt died later that afternoon.
Cause of death
22. There was no post-mortem examination and the Coroner accepted the cause of
death given by hospital doctors. They said that Mr Hillitt died from type 2 respiratory
failure (when the respiratory system fails to remove carbon dioxide from the body
sufficiently), which was caused by COPD. Obstructive sleep apnoea (when
breathing is interrupted during sleep), and prostate cancer were given as conditions
that contributed to but did not cause Mr Hillitt’s death.
Inquest
23. The inquest into Mr Hillitt’s death finished on 14 June 2024 and concluded that he
died of natural causes.
Adrian Usher
Prisons and Probation Ombudsman October 2023
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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